The Great Practice Makeover: Golden Ideas

If you ask Garrett Eckerling what’s new, make sure you have plenty of time for the answer. This dynamic, forward-thinking family physician always has a project or two or 50 in the hopper, all in the name of improving his practice.

Eckerling, whose solo practice is based in the California Gold Rush town of Grass Valley, constantly mines for the latest and greatest in terms of healthcare technology, medical equipment, and the like. “My whole attitude is you’ve got to keep changing, evolving, to stay one step ahead,” he says.

You’ll never catch Eckerling with his scrubs down when it comes to what’s new, and that’s certainly to his credit. But his staff dislikes being in constant flux, and he’s often disappointed in the results his projects produce. “Even as much as I research - although I’m pretty quick to take things up - many don’t stand up to advertising.”

For example, he invested in an in-office lab. Yes, it works, but it’s more than just the “one prick” touted by the sellers. Technically, that’s true. Actually administering the test is simple, but then there’s the part vendors routinely downplay: the increasingly dismal payer reimbursement for in-house lab work. These days, Eckerling regards his lab as more of a patient service than a profit-maker.

An impedance cardiography machine has fallen short as well, with much higher usage costs than anticipated. “I’ve got to do 20 a month, and leads are $10 each,” says Eckerling. His hope that the leads would come down in price has not come to fruition (although the vendor did recently conduct some additional training so that the practice could use the test more effectively).

Such water-in-the-face realities frustrate a personality like Eckerling’s. So many physicians stay safely within the status quo, good or bad, skeptical eyebrows eschewing change. But Eckerling is always looking for ways to improve his practice - a commendable trait.

It’s one that Connie Chatham, who staffs the check-in desk, certainly admires. “He has a good heart, he’s very bright, and he cares about his patients,” she says. Another trait she appreciates in her boss? His sensitivity to his employees’ lives outside of the office. “He’s very family-oriented. I can go to him and say, ‘I have to leave,’ and no matter what, even if he’s the only one there, he’ll say OK.”

Who wouldn’t appreciate a boss who truly believes in work-life balance? And who wouldn’t respect a physician who clearly will spend his hard-earned profits for the good of his patients? But …

“If everything’s going well, he’s got to change it,” Chatham says. “If he has a slow day, he’s coming up with projects.”

Marshal your resources

As a veteran medical office worker, Chatham certainly has the skills to be the office manager. But at this stage of her career, she prefers to train someone else to handle these responsibilities - namely, a young, energetic employee named Tiffany Hoyt.

Chatham is also a life-long resident of Grass Valley. She knows many of the patients who come to the practice, and she understands the nuances of small-town life. She says that the constant undulations of change within the office, from new technology to modifications in work flow, cause serious unrest among the patients - many of whom are senior citizens - and the employees. “He changes his mind 10-fold,” she says. “The girls around here work hard. If they stop and take a breather, he hands them another project.”

Wouldn’t written job descriptions ease that problem a bit? “We just had them done, but I think they’re all changed now,” says Chatham, who is not even sure she has a hard-and-fast job title.

Notably, Eckerling seems very aware that his decision-making style and unrelenting introduction of new ideas cause a near-constant, rippling unease through the practice. He has expressed a deep desire to learn how to more effectively make the decisions that cause change within the office. “Not just on the fly,” he says. “I want to understand the consequences, and get staff on board.”

With a little mental discipline, he can certainly make that happen. Here’s how he - and you - can accomplish that.

Define your overall purpose. Perhaps there’s something that really sets your clinical heart all a-twitter - asthma care, diabetes control, geriatrics. Or maybe you totally dig medical technology. Decide on one - and only one - area as a focal point for your practice. From now on, this focus will underpin every decision you make.

Set specific goals. Now that you know what you’re all about, you can start achieving it. Research and purchase equipment and software, attain certifications, and gain any other necessary skills for you and your staff.

But hold on there, pardner. You need to carefully plan by setting a reasonable number of goals. Taking on too much is a common foible of visionary types like Eckerling. Consider this schedule:

• One large annual goal - This is the overall purpose you just defined above. Let’s say it’s “high patient satisfaction.”

• Four midsized quarterly goals - You need to know where you stand right now with your patients. Use the first two quarters of the year to design and field surveys and analyze the results. That leaves quarters three and four to make targeted improvements.
  

• 12 small monthly goals - Is your patient flow like a skilled gondolier sculling through the canals of Venice? Or more like the herky-jerky boinging of a grasshopper freaking out inside your car? Being shuffled inefficiently through a practice can dampen patient moods. How about your patient billing? Fast, friendly, and understandable? Check on anything that touches your patients: phone manners, waiting room amenities, staff demeanor. Highlight one aspect each month.

• 52 mini weekly goals - This is where you “declutter,” either physically or operationally. These are small tasks, doable in one week or less, such as cleaning out the supply closet, devising and assigning job titles and descriptions, or researching new equipment.

To keep your plans both organized and top of mind, consider using a whiteboard as a master schedule that holds a quarter’s worth of project plans in grid form. You can use this tool to help break up large projects into smaller steps, as described in the text box “Project Management 101.”

Commit to these goals, once set. You don’t need to define every aspect of the year; even planning just one quarter at a time is helpful. Build in a couple of wildcards at the “weekly” level to satisfy your carpe diem needs. But promise yourself - and your staff - that you will stay with the plans you set up. Although occasionally it’s unavoidable, nobody likes to be constantly blind-sided with unanticipated work. By sticking to your scheduled goals, you’ll achieve what you want without inciting mutiny.

Come together

One of the best and worst parts about us human beings is our individuality. Energy levels from one person to the next range from snail-like to near light speed, as do tolerances for change. Possibly no one loves change more than Eckerling, and no one loves it less than Chatham.

Chatham’s tenure at this medical office (which predates Eckerling’s purchase of the practice a decade ago) and her life-long town residency make her a sort of practice “mom,” and indeed Eckerling tends to bounce his ideas off her. But this bouncing usually lands with a dull thud, because Chatham, with her big-picture view of the town and the idiosyncrasies of its residents, is a self-professed naysayer.

This results in Eckerling proceeding anyway and Chatham feeling like her opinion was ignored.

Eckerling’s zoomed-in approach evokes a great deal of angst in Chatham, partly because she simply doesn’t see the need for so much change, and partly because, as she notes, “[The admin staff] are the ones who have to deal with the realities of his ideas,” such as the new electronic check-in that stymies most of the practice’s senior-aged patients.

There’s no right or wrong here. Eckerling’s upbeat enthusiasm for improvement is laudable; people like this can inspire the pessimists. Conversely, Chatham’s love of homogeneity can help impulsive people slow down and think things through a bit better. But such opposites only attract if both types learn to work together. Otherwise, it’s stressful chaos, a never-ending tug-of-war.

The trick is to appreciate each other’s strengths, to treat each other with gentle and thoughtful respect. Certainly, Eckerling and his crew succeed in this to some degree already, or Chatham wouldn’t have stuck around for 10 years; indeed, his overall staff turnover is quite low. Still, there are some rough spots in the daily operations of this practice that, if smoothed out, would surely be welcomed by both employer and employees.

One way to build this sort of relationship is for all the deciders - in this case, Eckerling, Chatham, and office manager-in-training Hoyt - to congregate for regular updates. During these meetings, they should go over the status of the practice’s list of projects.

The mechanics of these sit-downs will make or break Eckerling’s resolve to improve his current methods of enacting change. Basically, people can’t listen unless they feel heard. Eckerling must resolve not to drown the others in new ideas, and when he asks, “What do you think?” he must truly listen to and reflect on the answers he gets. Yes, it’s his practice, and in the end he makes the final call, but a veteran healthcare worker and town resident is a valuable well of insider information on how changes might be received.

Chatham, conversely, must strive to keep her mind open to new ideas, and resist her habit of starting at “no” and working back from there. Rather, her focus should be on helping with the decision-making process by asking targeted questions about the finances, ROI, expected outcomes, efficacy, etc., of whatever Eckerling is excited about. This will support Eckerling in seeing all the pros and cons of his (possibly) great idea.

Finally, as an office manager-in-training, Hoyt’s involvement brings two benefits: She can contribute with her own ideas and questions, as well as help to smooth rough spots during these discussions, and all the while garner great experience in diplomacy - a rare and useful skill.

With a little practice and effort, all can feel heard and appreciated, and a divisive relationship can easily morph into a positive and productive one that will trickle down to the rest of the staff, and then to the patients.

Shirley Grace is associate editor for Physicians Practice. She can be reached at sgrace@physicianspractice.com.

This article originally appeared in the September 2008 issue of Physicians Practice.